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STATE OF CALIFORNIA °Oea <br /> STATE WATER RESOURCES CONTROL BOARD ~ _P ee'�....' <br /> a <br /> CERTIFICATION OF COMPLIANCE W�� �; <br /> FOR UNDERGROUND STORAGE TANK INSTALLATION .m z ; <br /> FORM C <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM <br /> I. SITE LOCATION ARCO FACILITY NO. 0-7Cp0 <br /> STREET CHeeoyE>Ey AwAE <br /> CITY 1-0p1 COUNTY nQa ,l �IoAC3u til <br /> II. INSTALLATION (mark all that apply): <br /> A The installer has been certified by the tank and piping manufacturers. <br /> ❑ The installation has been inspected and certified by a registered professional engineer. <br /> ® The installation has been inspected and approved by the implementing agency. <br /> [ All work listed on the manufacturer's installation checklist has been completed. <br /> ® The installation Contractor has been certified or licensed by the Contractors State License Board. <br /> ❑ Another method was used as allowed by the implementing agency.`(Please specify.) <br /> III. OATH I certify that tformation ovlded is true to the best of my belief and knowledge. <br /> Tank Owner/Agent Date 02/28/92 <br /> Print Name Arco oduct Co. - Environmental Health <br /> Phone ( ) <br /> andetVMe- Judy Mason 7-2605 <br /> Address 17315 Studebaker Rd. Cerritos, CA 90701 <br /> LOCAL AGENCY USE ONLY <br /> STATE CO�UNTYY# JURISDICTION# FACILITY# TANK# <br /> TANK I.D.# �f-1 I dLIE 51� <br /> "T� FT <br /> FORM C (7/91) THIS FORM MUST BE ACCOMPANIED BY PERMIT APPLICATION FORMS A&B UNLESS THEY HAVE BEEN FILED PREVIOUSLY FORD=7 <br /> `/ `d <br />